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T IH.TI VR(1(=RAM CONROTMATVJ)FOR X1 � TANks UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION(check an that apO Y) ABOVEGROUND PIPING UNDERGROUND PIPING c SUCTION ❑3.GRAVITY 459. SUCTION ❑3.GRAVITY 45S ❑I.PRESSU"fL ❑ r PE ❑1.PRESSURE �� 95.UNKNOWN a6z TION/ SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER ❑I.SINGLE L ❑ ❑2.DOUBLE WALL ❑99.OTHER URER ❑2 DOUBLE W ALL ❑95.UNKNOWN 463 461. i`SAN'C;FACTURER Iv1ANUFACTURER ❑6.FRP COMPATIBLE Wl100%METHANOL STEEL ❑6.FRP COMPATIBLE W/100%METHANOL 1,BARE STEEL 2.STAINLESS STEEL ❑7.GALVANIZED STEEL LESS STEEL ❑7.GALVANIZED STEEL 8. 99.OTHERIC COMPATIBLE WITH CONTENTS ❑95•UNKNOWN ❑4.FBERGLA3.PLASTIC SS 1ppTIBLE W/CONTEvTS O 9.CATHODIC PROTECTION ❑B.FLEXIBLE(HDPE) ❑99.OTHER ❑ ❑95.UNKNOWNa65.GLASS ❑ 464. p 5.STEEL W/COATING ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION p smell be sahmitted to the kxal agency) VIL PIPING LEAK DETECTION(Check all that apply)(A deser non ottlx tmnuormgptogram pgOVEGROUND PIPING a67. UNDERGROUND PIPING a66. SINGLE WALL PIPING FE LL PIPING PRESSL`RIZED PIPING(Check all that apply): D PIPING(Check all that apply): 1. ELECTRONIC LIVE LEAK DETECTOR 3-0 GPH TEST WITH AUTO PUMP RONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑ -OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHIM BFFFOR ,, �L4RM31LURE,AND SYSTEM DISCONNECTION IBLE AND VISUAL ALARMS. ❑2 \10NTHLY0.2 GPH TEST HLY 0.2 GPH TEST3. A\N'UAL INiEGRITI'TEST(0.1 GPH) AL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVE.,'FIONAL SUCLIOZSYSTEMS(Checkall that apply) ONAL SUCTION SYSTEMS ❑5 DAILY VISUAL TESTS ONIGPHING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEG ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SECTION SYSTEVS(NO VALVES IN BELOW GROUND PIPING): SELF MONITORING ❑7. SELF MON'1TORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑S. DAILY VISUAL\(ON'TTORLNG E39. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAriED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ]0. AGAR SS OND TLRBCheck one)SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS J3 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS C1 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b. DISCONNECTION?OFF FOR LEAKS,SYSTEM FAI[.URE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHIT OFF ❑c. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑I1 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12.ANNUAL INTEGRITY TEST(o.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM . SUCTIOWGRAVITY SYSTEM 13.CONTINUOUS Sl.'S•1P SENSOR+AUDIBLE AND VISUAL ALA RMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) ERG EMERGENCY GENERATORS ONLY(Check all that apply) 14. ENCYLNUOUS SUMP SENSOR W THO AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF ❑ AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW ❑15. AUTOSIATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16 ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17.DAILY VISUAL CHECK []17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT abs. 131. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469 DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH I INER MONITORING C' ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE c- DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein is true and accurate to the best of my knowledge. G/ aio. SIGNATU E F OWN R/ PE T Rt a DATE: 472. TITLE OF Ow . R/OPERATOR: NA'vIE F WNER/OP O� ): v 'r a�: t Expiration Date(Agency use only) a75. Permit Number(Agency use only) Pemnit Approve y(Agency use only) Rev.02/16/00 t,ttn•!/www_vnidncs.ore